View Medical Policies
For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.
Please refer member-specific questions to the Customer Care number on the back of the member card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.
To view drug policies, guidelines and supporting documentation, please visit our View Drug Policies page.
| Title | Last Updated | Category |
|---|---|---|
| Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation Open a PDF 7.01.42 | 2025-07-11 | Bone & Joints (Orthopedic) |
| Radioembolization (TARE) for Hepatic Tumors Open a PDF 7.01.69 | 2025-06-25 | Radiation Treatment |
| Psychological Testing Open a PDF 3.01.02 | 2024-12-30 | Behavioral Health (Psychiatry/Psychology) |
| Proton Beam Radiation Therapy Open a PDF 6.01.11 | 2025-08-28 | Radiation Treatment |
| Prolotherapy Open a PDF 8.01.10 | 2025-07-11 | Bone & Joints (Orthopedic) |
| Private Rooms Open a PDF 12.01.06 | 2024-12-04 | Miscellaneous |
| Prenatal Genetic Testing Open a PDF 4.01.03 | 2025-07-03 | Genetic Disease (Inherited Disease) |
| Predictive Testing for Pancreatic Cancer Open a PDF 2.02.39 | 2025-07-29 | Lab Tests (pathology) |
| Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 | 2025-09-11 | Durable Medical Equipment & Supplies |
| Positron Emission Tomography (PET)- Non-Oncologic Applications Open a PDF 6.01.07 | 2025-09-30 | Radiology (x-rays) & Imaging |
